In the Event a Student Requires Medical Attention While Studying Abroad, It Is Important

In the event a student requires medical attention while studying abroad, it is important for appropriate Quinnipiac University officials, if contacted, to have access to up-to-date information about that student’s medical history. For this limited purpose only, each student participating in a study abroad program is required to complete this Study Abroad Health History Form. Any student who does not fill out this form completely and accurately does so at his or her own risk.

I, (Full Name) ______, (Student ID) ______, understand that all students participating in an international study abroad program endorsed by Quinnipiac University (QU) will be required to purchase QU’s Study Abroad Accident and Sickness Insurance Plan, including Medical and Security Assistance. This insurancewill cover most illnesses, everyday accidents, emergency medical treatment, security evacuations, and the repatriation of remains. I understand that certain activities that may result in illness, injury, property damage, or death to myself or others, including but not limited to scuba diving, jet-skiing, snow-skiing or snow-boarding, water-skiing, mountain climbing, biking, skydiving, bungee jumping, white water rafting, surfing, or parasailing, may be excluded from this insurance coverage, leaving me personally responsible. I understand and agree that it is my responsibility to review QU’s Study Abroad Accident and Sickness Insurance Plan and ask any questions about what is and is not covered and conduct myself accordingly. The expense of the Study Abroad Accident and Sickness Insurance Planis a required cost of the trip, and will be displayed as a separate line item on my QU billing invoice.

I understand that the foreign location(s) at which I am studying or traveling may not regularly employ healthcare professionals and that accessibility to healthcare services and facilities may be limited or different from those to which I have become accustomed in the United States. In addition, appropriate treatments, especially psychological and psychiatric treatments, may not be as readily available, or available at all,as they are in the United States. I understand that I should make any necessary arrangements before my departure to refill prescription medications, obtain items needed for special diets, and otherwise account for my ongoing healthcare needs. I also agree, before my departure, to ensure that my health information is up-to-date with Student Health Services, which can be reached at (203) 582-8742.

I understand that I must discuss with the QU study abroad program officer any special concerns or needs (e.g., physical limitations or learning disabilities) that may require advance arrangements for my participation in the study abroad program. I understand that because no QU official reads this form in advance of my trip, and will never read it unless called up to do so due to a medical event involving me during the program, disclosure on this form of any such matters is not sufficient.

➡Please indicate “yes” or “no” to the following:

__ yes __ no I suffer from, have been diagnosed with, or otherwise consider

myself to have a medical or psychological condition.

__ yes __ no I have allergies to food and/or prescription drugs.

➡If you have indicated yes to either of the items listed above, please describe your answer in sufficient detail such that QU, if called upon, could explain your answer to a medical professional (you may attach an additional sheets as necessary): ______

➡Please list any medication(s) you are currently taking or expect to be taking while studying abroad:
______

➡Please indicate any other information not addressed above about your health or that you would want to be made available to medical personnel should you need to receive medical treatment (e.g., religious restrictions regarding medical care; dietary restrictions, etc.). ______

I acknowledge and agree that:

A.In the event of illness or injury to me, an appropriate representative of QU may authorize medical treatment on my behalf and/or providehealthcare officials with the information about my medical history on this form so informed medical decisions can be made.

B.I will accept financial responsibility for any medical/emergency treatment that is not covered by my insurance.

C.I understand that QU may take any action it considers necessaryto protect my health and safety, including sending me home from the study abroad location. I agree to pay all expenses relating to such travel.

D.Neither QU nor any of its trustees, officers, employees, or agents shall be liable for anyinjury, death, damage to person or property, or expensesarising out of my medical treatment by any doctor,hospital, pharmacy or other healthcare facility to whom I may bereferred by the study abroad program or to whom I have gone for treatment, advice, orassistance onmy own accord.

E.I acknowledge and understand the responsibilities and conditions in this agreement, and have had ample time to consider them prior to signing my name below. If there is a dispute involving the interpretation or application of this agreement, I agree that it will be resolved in an arbitration proceeding conducted in accordance with the rules of the American Arbitration Association and governed by Connecticut law.

F.I am at least eighteen (18) years old, have read the foregoing, and sign it voluntarily and without duress.

FERPA Release

In case of a medical emergency while studying abroad, I consent to QU’s disclosure of this Study Abroad Health History Form to appropriate officials at my Study Abroad Affiliate, Host Institution and/or Host Family in order to assist with my medical care and treatment. I understand that according to the Federal Education Rights and Privacy Act of 1974 (FERPA), no disclosure of my records can be made without my written consent unless otherwise provided for by law.

DATE: ______SIGNATURE: ______

Medical Release

In case of a medical emergency while studying abroad, QU asks for your permission to release your medical information to your parents, family members, or other responsible party.

Check one:

___ I authorize an appropriate QUofficial to contact the individuals listed below to provide them with medical information if I need medical care while studying abroad.

___ I do not authorize an appropriate QUofficial to release my medical information to anyone butthe medical providers involved in my care and treatment if I need medical care while studying abroad.